Lit Bits: Sept 13, 2010

From the recent medical literature...

1. Stress Cardiac MRI with Observation Unit Care Reduces Cost for Patients With Emergent Chest Pain: A Randomized Trial

Chadwick DM, et al. Ann Emerg Med. 2010;56:209-219.e2

Introduction
Background
Current guidelines from the American College of Cardiology and the American Heart Association suggest that patients being evaluated for acute coronary syndrome without diagnostic ECGs or biomarkers may be further evaluated in an observation unit. In practice, patients at intermediate or high probability of experiencing acute coronary syndrome, such as patients with previous myocardial infarction, diabetes, or advanced age, are commonly admitted to the hospital. After admission, these patients frequently receive highly variable and aggressive care, with cardiac catheterization rates as high as 37% to 56%.

Cardiac magnetic resonance imaging (MRI) is an established stress-testing modality, with sensitivity and specificity superior to that of stress echocardiography and without the radiation exposure or radioisotope-related time delays associated with nuclear testing. It has proven to be highly accurate for identifying acute coronary syndrome in patients presenting with emergent chest pain in a research setting. Cardiac MRI testing is appealing because it can detect recent infarction before biomarker increase, identify inducible myocardial ischemia, and differentiate between new and old myocardial infarctions. The comprehensive information provided by stress cardiac MRI makes it appropriate for most non-low-risk patients with emergent chest pain, including those with known coronary artery disease. These attributes also make it well suited for protocol-driven rapid care units.

Importance
Improving the efficiency of chest pain evaluations through the use of observation units could reduce the risk of such evaluations. The strengths of cardiac MRI testing and its high accuracy suggest that cardiac MRI is an ideal test for integration into an observation unit care pathway. However, implementing a cardiac MRI testing program requires equipment purchases and personnel training; for these reasons, it is associated with “up-front” expenses. For this to be a worthwhile investment, a cardiac MRI strategy would have to represent an improvement over existing models of care delivery. Therefore, the cost associated with a cardiac MRI care strategy should be examined.

Goals of This Investigation
The purpose of this trial was to integrate cardiac MRI testing with observation unit care among patients with emergent non-low-risk chest pain and compare direct medical cost of this care pathway with that of conventional inpatient care.

Abstract
Study objective
We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.

Methods
Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.

Results
There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.

Conclusion
Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00375-6/fulltext

2. A Clinical Decision Rule to Identify Infants with Apparent Life-threatening Event Who Can Be Safely Discharged from the ED

Sun G, et al. Acad Emerg Med. 2010;17(5) Supplement 1;S70 (abstract 205)

Introduction: Recent studies have questioned the need to hospitalize all infants with an apparent life-threatening event (ALTE), but the ability to identify those who can be safely discharged from the emergency department (ED) is lacking.

Objective: To formulate a clinical decision rule (CDR) to identify infants with ALTE at low risk of adverse outcome who can be safely discharged from the ED.

Methods: Prospective cohort study of infants with an ED diagnosis of ALTE. Detailed information about the visit and 4-week follow-up were collected. Admission was considered warranted if the infant required any significant intervention (SI) during hospital stay (e.g., parenteral antibiotics for proven infection, airway management, admission to ICU) or had a recurrence of ALTE leading to a repeat ED visit within 72 hours. Logistic regression and recursive partitioning analysis were used to develop and validate a CDR identifying patients at low risk of SI and thus suitable for discharge from the ED.

Results: Three hundred infants were enrolled; 228 (76%) were admitted; 37 (12%) required SI. None died during hospital stay or within 72 hours of discharge, or was diagnosed with serious bacterial infection (bacterial meningitis, bacteremia, or UTI). Of the 286 subjects with complete case data who underwent further analysis, 35 (12%) met criteria for SI. Logistic regression identified prematurity (OR 4.5, 95% CI 2-9.9), abnormal physical exam in the ED (3.4, 1.6-7.5), color change to blue (3.2, 1.4-7.2), absence of reported cough or runny nose (2.9, 1.1-7.9), and absence of history of choking (2.3, 1.1-5.1) as predictors for SI. These variables were used to create a CDR. Based on this model (terminal nodes 1, 2, and 5 indicating subjects at low risk), 184 (64%) infants could be discharged home safely from the ED. The model has a negative predictive value of 96.2% (92-98.3).

Conclusion: Only 12% of infants presenting to the ED with an ALTE had a significant intervention warranting hospital admission. We created a CDR that would have that would have decreased the admission rate safely from 76% (observed) to 36%.

Analyzing the data, the researchers discovered that almost any infant in the study could have been safely discharged if they met one of the following criteria:

• Born at term and whose color did not change to blue
• Born at term, color change to blue, with a history of choking and normal exam in ED
• Born preterm and with a history of URI symptoms in the prior 24 hours

Work in now underway to validate the rule in other centers.

Article in ACEP News: http://www.acep.org/acepnews.aspx?id=49207

3. The ROSE (risk stratification of syncope in the emergency department) study

Reed MJ, et al. J Am Coll Cardiol. 2010;55:713-21.

OBJECTIVES: The aim of this study was to develop and validate a clinical decision rule (CDR) to predict 1-month serious outcome and all-cause death in patients presenting with syncope to the emergency department.

BACKGROUND: Syncope is a common, potentially serious condition accounting for many hospital admissions.

METHODS: This was a single center, prospective, observational study of adults presenting to the emergency department with syncope. A CDR was devised from 550 patients in a derivation cohort and tested in a validation cohort of a further 550 patients.

RESULTS: One-month serious outcome or all-cause death occurred in 40 (7.3%) patients in the derivation cohort. Independent predictors were brain natriuretic peptide concentration more than 300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin less than 90 g/l (OR: 6.7), oxygen saturation 94% or lower (OR: 3.0), and Q-wave on the presenting electrocardiogram (OR: 2.8). One-month serious outcome or all-cause death occurred in 39 (7.1%) patients in the validation cohort. The ROSE (Risk stratification Of Syncope in the Emergency department) rule had a sensitivity and specificity of 87.2% and 65.5%, respectively, and a negative predictive value of 98.5%. An elevated B-type natriuretic peptide (BNP) concentration alone was a major predictor of serious cardiovascular outcomes (8 of 22 events, 36%) and all-cause deaths (8 of 9 deaths, 89%).

CONCLUSIONS: The ROSE rule has excellent sensitivity and negative predictive value in the identification of high-risk patients with syncope. As a component, BNP seems to be a major predictor of serious cardiovascular outcomes and all-cause death. The ROSE rule and BNP measurement might be valuable risk stratification tools in patients with emergency presentations of syncope and should now be subjected to external validation.

Comment by Eric C. Bruno, MD

Syncope remains an elusive beast. Patients are routinely at their baseline upon arrival in the emergency department, making the evaluation somewhat limited. Clinicians were given a clinical decision rule, the San Francisco Syncope Rule, but it was later unable to be validated. Clinical judgement was the best predictor in that failed validation study. The authors of this prospective observational study took a stab at creating a clinical decision rule, selecting 32 predetermined variables, that would predict a serious event within 30 days of the presentation. Considering the funding, the true intent of the study was to determine if the provided Biosite (R) B-type natriuretic peptide (BNP) marker was an effective predictor of serious events. The authors seemingly attempted to shoehorn a decision rule around the BNP test.

The results did, in fact, show that an elevated BNP greater than 300 does anticipate serious outcomes as well six other factors … that predicted the clinically significant events, including myocardial infarction, arrhythmia, and intracranial hemorrhage. The authors created a double pneumonic (the ROSE study resulting in the BRACES clinical rule) which will ultimately lead to some level of confusion. Fortunately, the researchers validated their own study in this paper.

4. Alteplase Is Effective Up to 4.5 Hours after Onset of Ischemic Stroke

But earlier is better.

On the basis of reports published in September 2008 from two large international studies, professional stroke organizations extended the recommended time between symptom onset and administration of alteplase from 3 to 4.5 hours (JW Emerg Med Sep 24 2008 and JW Emerg Med Sep 15 2008). To assess implementation of the wider treatment window and its effects, investigators analyzed data for nearly 24,000 patients who were included in one of the study's stroke registry from 2002 to 2010.

Overall, 2376 patients received alteplase between 3 and 4.5 hours after symptom onset; the proportion of patients who were treated within this window was three times higher in the last quarter of 2009 than in the first quarter of 2008. Rates of poor outcomes were low: 7.1% of patients treated within 3 hours and 7.4% of those treated at 3 to 4.5 hours had symptomatic intracerebral hemorrhage and 12.3% and 12.0%, respectively, died within 3 months. However, in analyses adjusted for confounding variables, patients treated at 3 to 4.5 hours had significantly higher rates of symptomatic intracerebral hemorrhage (1 extra hemorrhage for every 200 patients) and 3-month mortality (1 extra death for every 333 patients), as well as significantly worse functional outcomes (odds ratio for functional independence, 0.84). Median time from admission to treatment was 65 minutes before and after the reports. The authors conclude that the extended treatment window was implemented rapidly with no overall increase in admission-to-treatment time and that although risk from alteplase was greater when administered at 3 to 4.5 hours, treatment was still beneficial.

Comment: Although the U.S. FDA has not yet approved use of alteplase beyond 3 and up to 4.5 hours after onset of ischemic stroke symptoms, this evidence supports a wider treatment window and professional organizations recommend it. Nevertheless, time is brain, and eligible patients should be treated as soon as possible.

— Kristi L. Koenig, MD, FACEP. Published in Journal Watch Emergency Medicine August 27, 2010. Citation: Ahmed N et al. Lancet Neurol 2010 Sep; 9:866.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20667790

5. Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated MRSA Infection

Schmitz GR, et al. Ann Emerg Med. 2010;56:283-287.

Abstract
STUDY OBJECTIVE: Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days.

METHODS: In this multicenter, double-blind, randomized, placebo-controlled trial, we randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage. Using emergency department rechecks at 2 and 7 days and telephone follow-up, we assessed treatment failure within 7 days, and using clinical follow-up, telephone follow-up, and medical record review, we recorded the development of new lesions within 30 days.

RESULTS: We randomized 212 patients, and 190 (90%) were available for 7-day follow-up. We observed a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval -2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02.

CONCLUSION: After the incision and drainage of uncomplicated abscesses in adults, treatment with trimethoprim-sulfamethoxazole does not reduce treatment failure but may decrease the formation of subsequent lesions.

6. Serotonin Syndrome: Case Report and Review

Serotonin syndrome is a potentially life-threatening adverse drug reaction that results from therapeutic drug use, usually of selective serotonin reuptake inhibitors (SSRIs), intentional excessive use or interactions between various drugs. It is not an idiopathic reaction and occurs due to excess serotonin activity in the brain and periphery. The serotonin syndrome was first described in 1959 in a patient with tuberculosis who received meperidine and died. The syndrome received its current name in 1982. The significance of serotonin syndrome was brought to attention in 1984 when Libby Zion, an 18-year-old college student, presented to a New York hospital with fever, agitation and confusion. The child was on phenelzine, a monoamine-oxidase inhibitor (MAOI) antidepressant. She was given meperidine in the hospital for agitation. She became increasingly agitated and hyperpyrexic with a temperature of 41.6°C and died 6 h later.

Epidemiology
Serotonin syndrome has been reported in all age groups. There has been a reported increase in its incidence because of the increasing use of proserotonergic agents over the last few years. In 2004, the Toxic Exposure Surveillance System (TESS) reported 48,204 exposures from SSRIs that resulted in moderate or major outcomes in 8,187 patients, including 103 deaths. The serotonin syndrome has been reported to occur in approximately 15% of persons who overdose SSRIs. The true incidence is difficult to assess because of lack of awareness of this clinical entity amongst physicians, and indeed one survey found that 85% of physicians were unaware of this syndrome.

The remainder of the text (free): http://www.springerlink.com/content/q382111247766427/fulltext.html

7. The Likelihood of Acute Pulmonary Embolism in ED Patients Is Not Lower Among Patients Taking Warfarin

Nordenholz K, et al. Acad Emerg Med. 2010;17(5) Supplement 1;S2 (abstract 4)

Background: Patients commonly require testing for pulmonary embolism (PE) while on warfarin for previous PE, deep venous thrombosis, or atrial fibrillation.

Objective: To determine whether, among emergency department (ED) patients evaluated for PE, the ‘‘rule in’’ rates vary according to the presence or absence of warfarin and the international normalized ratio (INR) level.

Methods: A secondary analysis of a prospective, observational study of 7940 ED patients from 13 centers who had a diagnostic test for PE and for whom 45 day PE outcomes were known by record review and phone follow-up. Data were collected about warfarin use, INR, presence or absence of cancer, and diagnosis of acute PE. INR was defined as therapeutic (TR) (1.5-2.5), high (above 2.5), low (below 1.5), or INR was either not measured or not recorded (NM).

Results: The table shows the rule-in rate of PE among all patients and in strata defined by warfarin use and by INR level. The PE rate was not lower in patients taking warfarin, regardless of INR. The presence of active, metastatic, or inactive cancer was not an effect modifier and did not alter these findings. The data set is limited by testing bias and INRs NM.

Conclusions: Among ED patients with suspected PE who are taking warfarin, half do not have an INR recorded. However, a therapeutic or high INR is not associated with a lower likelihood of acute PE diagnosis and should not be used alone to withhold PE testing. Further investigation is warranted to discriminate this particular PE population.

8. Dilute proparacaine for the outpatient management of acute corneal injuries in the ED

Ball IM, et al. CJEM 2010;12(5):389-396

Objective: Dogma discourages the provision of topical anesthetics to patients with corneal injuries discharged from the emergency department because of the toxicity of concentrated solutions. We compared the analgesic efficacy of dilute topical proparacaine with placebo in emergency department patients with acute corneal injuries.

Methods: We conducted a prospective randomized controlled trial of adults with corneal injuries presenting to one of 2 tertiary care emergency departments in London, Ont. Patients were randomly assigned to groups receiving either 0.05% proparacaine or placebo drops as outpatients and were followed up to healing by a single ophthalmologist. Our primary outcome was pain reduction as measured on a 10-cm visual analog scale.

Results: Fifteen participants from the proparacaine group and 18 participants from the placebo group completed the study. The mean age of the patients was 38.7 (standard deviation 12.3) years and the majority were male (85%). Pain reduction was significantly better in the proparacaine group than in the placebo group, with a median improvement of 3.9 (interquartile range [IQR] 1.5–5.1) cm on the visual analog scale versus a median improvement of 0.6 (IQR 0.2–2.0) cm (p = 0.007). The proparacaine group was more satisfied (median level of satisfaction 8.0 [IQR 6.0–9.0] cm on a 10-cm visual analog scale v. 2.6 [IQR 1.0–8.0] cm, p = 0.027). There were no ocular complications or signs of delayed wound healing in either group.

Conclusion: Dilute topical proparacaine is an efficacious analgesic for acute corneal injuries. Although no adverse events were observed in our study population, larger studies are required to evaluate safety.

9. Bronchiolitis Illness Duration and Caregiver Burden: An Inconvenient Truth

The median duration of illness in infants with first-time bronchiolitis was 15 days.

Petruzella FD, Gorelick MH. Pediatrics. 2010;126:285-90.

OBJECTIVES: To describe the duration of illness in infants with first-time bronchiolitis who present to an emergency department (ED) and assess the burden of the illness on caregivers and families.

METHODS: This was a prospective cohort study of infants younger than 12 months who presented to a tertiary care children's hospital ED with a first episode of bronchiolitis. Subjects were excluded if they had a history of bronchodilator use or immunocompromise. Demographic and clinical data were collected in the ED. Outcomes data were collected by weekly telephone interviews for 4 weeks or until the subject was free of cough for 24 hours.

RESULTS: Ninety-five infants were enrolled from November 2007 to March 2008. Median duration of symptoms was 15 days; 25% of the infants remained symptomatic after 21 days. Subjects with a history of eczema trended toward a longer median duration of symptoms when compared with those who did not (18 days [interquartile range (IQR): 15.5-24] and 15 days [IQR: 11-19], respectively; P = .055). Duration of symptoms did not significantly vary with regards to respiratory syncytial virus status or secondhand smoke exposure. Subjects missed a median of 2.5 days (IQR: 0.5-5.5) of day care, and caregivers missed a median of 2 days (IQR: 1-4) of work. Of these infants, 37.1% (95% confidence interval: 24.3-44.1) had a subsequent unscheduled medical visit.

CONCLUSIONS: Infants seen in the ED for bronchiolitis have a prolonged disease course, with substantial burden to the family. Symptom duration may be influenced by a propensity toward atopy. Clinicians may use this information for counseling families.

10. Biphasic DC shocks for paediatric atrial dysrhythmias: Which dose is best?

Tibballsa J, et al. Resuscitation 2010;81:1101-1104.

Objective
To determine cardioversion doses of biphasic DC shock for paediatric atrial dysrhythmias.

Design
Prospective recording of energy, pre-shock and post-shock rhythms.

Setting
Paediatric hospital.

Patients
Shockable atrial dysrhythmias.

Main results
Forty episodes of atrial dysrhythmias among 25 children (mean age 6.8±7.1 years, mean weight 28.2±28.5kg) were treated with external shock. The first shock converted the dysrhythmia to sinus rhythm in 25 episodes. Cardioversion occurred in 2 of 8 (25%) episodes with a dose of less than 0.5 J/kg, 14 of 16 (88%) with a dose of 0.5–1.0J/kg and 9 of 16 (56%) with a dose of above 1.0 J/kg (p=0.01, Fisher's exact test). Ten of 15 initially non-responsive episodes were cardioverted with additional shocks at 1.1±0.6J/kg (range 0.5–2.1J/kg). Of the remaining 5 unresponsive episodes, 2 of ventricular fibrillation (induced by unsynchronized shock) were successfully defibrillated, and 3 were managed with cardiopulmonary bypass. Among 11 additional children (mean age 4.3±6.8 years, mean weight 18.1±22.0kg), 18 episodes of atrial dysrhythmias were treated with internal shock which successfully cardioverted all episodes with one or more shocks at 0.4±0.2J/kg.

Conclusions
In rounded doses, recommended initial external cardioversion doses are 0.5–1.0J/kg and subsequently up to 2J/kg, internal cardioversion doses are 0.5J/kg.

11. Balancing Work, Family and Friends, and Lifestyle

Alpert JS. Amer J Med. 2010;123:775-776.

Discussing the balance in a person's life resembles conversations about managing stressful times. As I write this, my daughter, Eva, an accountant and tax attorney, is in the final phase of her stressful and very hectic “busy season” as the April 15th tax deadline draws near. Some people think of those stressful times as periods in which their work/life/family–friends balance is unbalanced, and personal and professional fulfillment seems very far away. The stresses in our lives often make us feel uncomfortable, nervous, and anxious. At these times we wish that our daily activities could meld better so that the stress-induced discomfort would fade away, and we would feel more balanced. Each individual has a different sense of what these entities entail, and each of us undoubtedly feels strongly about what causes stress in our life or how to balance work, play, and human relationships.

Recently, I was asked to deliver a lecture to a group of early career cardiologists attending the annual scientific sessions of the American Heart Association. It was unclear to me at the time why I was chosen for this task and was not convinced that my life represented the ideal of balanced work and lifestyle. Nevertheless, I searched the Internet for clues concerning advice about balancing one's life. In this essay, I will discuss some of the recommendations derived from this exercise in browsing combined with some personal opinion based on experience. There is no doubt in my mind that others will disagree with my priorities, but, as I have already stated, each of us will have different concepts and beliefs on this topic.

…Professional healthcare workers have very demanding educational and work schedules. Family and close friends often fail to understand the work pressures involved in our field. Despite the great physical and psychological requirements in our daily routine, most of us hope to be seen as human beings who can simultaneously involve ourselves in our families, our jobs, and our community. Given these demands, how can we achieve balance in our lives without making major sacrifices that might lead to psychological distress, indeed, a form of posttraumatic stress syndrome? I cannot claim to have the perfect solution to this conundrum. However, I will outline some of the ways that have been suggested by others and approaches that I have found to be effective….

The remainder of the essay (free): http://www.amjmed.com/article/S0002-9343(10)00356-6/fulltext

12. Nasal foreign bodies in children: kissing works half the time

Taylor C, et al. Emerg Med J 2010;27:712-713.

Objective: To evaluate the use, success rate and time in the paediatric emergency department when employing the kissing technique to remove nasal foreign bodies from children.

Methods: The present work was a retrospective case note review for children attending with a nasal foreign body over a 15-month period.

Results: In all, 116 children had a confirmed nasal foreign body and 84 were treated by the kissing technique with a success rate of 48.8%. This group had lower rates of instrumentation (20.2% vs 53.1%) and general anaesthesia (11.9% vs 18.8%). The average time saved per patient who had the kissing technique attempted in the paediatric emergency department was 30.6 min.

Conclusion: The kissing technique should be employed as a preferred technique to remove nasal foreign bodies in children.

13. Urinalysis Is an Inadequate Screen for Rhabdomyolysis

Ruegner R, et al. Acad Emerg Med. 2010;17(5) Supplement 1;S45 (abstract 131)

Objectives: The classic screening test for rhabdomyolysis is a positive urine dip for blood, but negative microscopy. Our objective was to determine the sensitivity of the urinalysis (UA) in the diagnosis of rhabdomyolysis.

Methods: Retrospective electronic chart review of all patients with a primary or secondary discharge diagnosis of rhabdomyolysis admitted from 2003-2009 at a university-affiliated Level I trauma center. A creatine kinase (CK) over 1000 U/L and UA within 24 hours of presentation were also required for inclusion. Using a standardized data form, we collected demographic information, laboratory values (initial, peak, final), treatment, and disposition. For study purposes we defined a ‘‘positive’’ UA as dip positive for blood (trace or more) but negative microscopy (3 RBC or fewer). We calculated the sensitivity and 95% confidence interval (CI) of the UA in the detection of rhabdomyolysis.

Results: Of 1,796 records reviewed, 228 patients met all inclusion criteria. The mean age was 46 years (range 15-102) and 79% were males. Twenty-nine percent of the cases were associated with illicit drug use, 12% seizure, 11% sepsis, 4% trauma, 1% heat illness, and the remainder were unknown. The mean initial CK was 17,371 (range 56 - 278,000), and mean peak CK was 27,509 (range 1,166-404,700). One hundred and ninety-five (86%) had a urine dip positive for blood, but only 94 had the combination of a positive dip but negative microscopy, yielding a sensitivity of 41% (95% CI, 35%-47%) for detecting rhabdomyolysis. Broadening the definition of negative microscopy to less than 10 RBC would increase sensitivity to 79% (95% CI, 73%-83%). In the subset of 66 patients with more severe rhabdomyolysis and an initial CK greater than 10,000 (mean
53,365), the sensitivity of the UA was 55% (95% CI, 43%-67%). Overall mortality was 18%.

Conclusions: The combination of a positive urine dip for blood and negative microscopy is an insensitive screening test for rhabdomyolysis and should not be used alone to exclude the diagnosis.

14. Delayed Sequence Intubation (DSI)

By Scott Weingart, MD. ACEP News, July 2010

The Case

You have a 50-year-old male with bad bilateral pneumonia; BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal cannula; when you try to place the patient on a non-rebreather (NRB), he just swats your hand away and rips off the mask.

It is obvious to everyone in the room that this patient needs intubation -- but the question is, how are you going to do it?

Your first impulse may be to perform rapid sequence intubation (RSI), maybe with some bagging during the paralysis period. This is essentially a gamble.

If you have first-pass success with RSI, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability.

However, the odds are against you: Bagging during RSI predisposes to aspiration; conventional bag valve mask (BVM) without a positive end expiratory pressure (PEEP) valve is unlikely to raise the saturation in this shunted patient; and if there is any difficulty in first-pass tube placement, your patient will be in a very bad place.

A Better Way

Sometimes patients such as this one who desperately require preoxygenation will impede its provision.

Hypoxia and hypercapnia can lead to a state of delirium, causing these patients to rip off their NRB or noninvasive ventilation (NIV) masks.

This delirium, combined with the low oxygen desaturation on the monitor, often leads to precipitous attempts at intubation without adequate preoxygenation.

Standard RSI consists of the simultaneous administration of a sedative and a paralytic agent and the provision of no ventilations until after endotracheal intubation. This sequence can be broken to allow for adequate preoxygenation without risking gastric insufflation or aspiration; we call this method "delayed sequence intubation" (DSI).

DSI consists of the administration of specific sedative agents, which do not blunt spontaneous ventilations or airway reflexes, followed by a period of preoxygenation before the administration of a paralytic agent.

Another way of thinking about the DSI method is to view it as a procedural sedation--with the procedure in this case being effective preoxygenation.

After the completion of this procedure, the patient can be paralyzed and intubated. Just as in a procedural sedation, we want patients to be calm but still spontaneously breathing and protecting their airway.

The rest of the essay: http://www.acep.org/acepnews.aspx?id=48971

15. Images in Emergency Medicine

Woman with Neck Pain and Swelling
http://www.annemergmed.com/article/S0196-0644(09)01546-7/fulltext

Asterixis
http://www.nejm.org/doi/full/10.1056/NEJMicm0911157

Miliary Tuberculosis
http://www.nejm.org/doi/full/10.1056/NEJMicm1001480

Acute maxillary sinusitis detected by bedside ED ultrasonography
http://www.springerlink.com/content/m4147580675138vh/fulltext.html

Pneumomediastinum from nasal insufflation of cocaine
http://www.springerlink.com/content/33077g51t88gk488/fulltext.html

Diffuse ST segment depression from hypothermia
http://www.springerlink.com/content/q488tq1168m0t773/fulltext.html

Isolated uvular angioedema: Quincke’s disease
http://www.springerlink.com/content/y137466n62k8k080/fulltext.html

A potentially fatal cause of rash
http://www.springerlink.com/content/y37017062041k375/fulltext.html

16. Managing anaemia in non-bleeding critically ill adults: state of the evidence

Walsh TS, et al. BMJ 2010; 341:c4408.

Introduction
Anaemia (haemoglobin below 12.0 g/dl for women, and below 13.0 g/dl for men) is common in acutely unwell patients. Maintaining sufficient oxygen transport to the tissues is fundamental to survival and recovery from acute illness, and in the United Kingdom 8-10% of the blood supply is used to treat patients in intensive care. Red blood cells transport more than 97% of the oxygen content of blood—about 200 ml/l—and anaemia greatly reduces oxygen delivery, especially if patients also have cardiovascular and respiratory compromise.

Transfusion of donor (allogeneic) red blood cells is the standard method for rapidly correcting anaemia in acutely unwell patients, but the risk-benefit balance of this intervention is a subject of continuing debate, controversy, and concern. We highlight uncertainties in the management of anaemia in critically ill patients, especially in relation to the use of red cells, and summarise current evidence from observational studies and randomised trials. We focus on the management of anaemia in critically ill patients without active bleeding, such as those who are in adult medical and surgical intensive care units, high dependency units, and other acute units. We do not discuss the management of patients with major haemorrhage, for which recent evidence is available elsewhere.

Summary points
Acute anaemia is common in critically ill patients

Several factors, including blood sampling and reduced red cell production associated with systemic inflammation, can contribute to anaemia

The risk-benefit profile for red cell transfusions to treat anaemia in non-bleeding critically ill adults is uncertain, but they may contribute to adverse patient outcomes in some situations

Best evidence suggests that using single unit red cell transfusions when haemoglobin is close to 7.0 g/dl and aiming for a haemoglobin of 7.0-9.0 g/dl is not harmful in most patients

Aiming for a haemoglobin nearer to 9.0-10.0 g/dl might be better for patients with acute cardiac disease and the early stages of severe sepsis

What haemoglobin concentration should trigger blood transfusion in critically ill patients?

The best evidence on what haemoglobin concentration should trigger transfusions in critically ill patients comes from a well performed non-blinded multicentre Canadian trial published in 1999 (the TRICC trial; summarised in box 3), which is widely considered the most important trial in transfusion medicine. Patients with a haemoglobin 9.0 g/dl or less were randomised to either a relatively high haemoglobin transfusion trigger of less than 10.0 g/dl with a target of 10.0-12.0 g/dl (the “liberal” group) or a lower haemoglobin transfusion trigger of less than 7.0 g/dl with a target of 7.0-9.0 g/dl (“restrictive” group). The findings strongly support using red cells only to maintain a haemoglobin concentration of 7.0-9.0 g/dl, especially in younger or less severely ill patients. The generalisability of these findings are unclear, however, and this might explain why clinical practice still varies. This trial has never been replicated in adult critical care, and a recent Cochrane systematic review noted the need for further trials.

Summary of key findings of the TRICC trial
Population
Non-bleeding critically ill patients whose haemoglobin value was 9.0 g/dl or less during the first three days in the intensive care unit

Intervention and comparator
The trial compared a restrictive strategy (haemoglobin transfusion trigger less than 7.0 g/dl; target value 7.0-9.0 g/dl) with a liberal strategy (haemoglobin trigger 10.0 g/dl; target value 10.0-12.0 g/dl) for managing anaemia with blood transfusions during the intensive care unit stay

Outcomes
The restrictive group received 54% fewer units of blood and 33% received no blood transfusions in the intensive care unit, whereas all of the liberal group were transfused

The restrictive group showed a non-significant trend towards lower mortality (18.7% v 23.3%; P=0.11)

The restrictive group had lower rates of cardiac complications (13.2% v 21.0%) and new organ failures (difference in multiple organ dysfunction score of 1 between the groups)

The liberal group showed a trend towards higher rates of acute respiratory distress syndrome (11.4% v 7.7%)

Predefined subgroup analyses
Younger patients (below 55 years) and patients with lower illness severity during the first 24 hours in the intensive care unit (APACHE II score less than20) had significantly better outcomes when they were in the restrictive group (these patients were more anaemic and received fewer blood transfusions)

Subgroup analyses that were not predefined (post hoc analyses)
There was a trend for patients with known ischaemic heart disease to have better outcomes in the liberal group

No differences in outcomes were seen in the subgroup of patients who were mechanically ventilated.

Uncertainties about the generalisability of the findings
The blood used was not leuco-depleted. Transfused leucocytes may have adverse effects in critically ill patients and most countries now routinely leuco-deplete blood before storage.

The storage age of the blood was unknown. Longer storage times might affect patient outcomes, especially if the blood was not leuco-depleted.

The study could not prove that the restrictive approach was safe for all patient subgroups, especially those with heart disease and sicker older patients.

Improvements in critical care and blood processing over the past decade might mean the findings would be different if the trial were repeated now.

Link: http://www.bmj.com/content/341/bmj.c4408

17. Which Oral Rehydration Solution Tastes Best?

Children preferred Pedialyte and Pediatric Electrolyte to Enfalyte.

Freedman SB, et al. Arch Pediatr Adolesc Med. 2010;164:696-702.

OBJECTIVE: To compare the palatability of 3 oral rehydration solutions.

DESIGN: Prospective, blinded, randomized, 3-period, 3-treatment crossover trial.

SETTING: Emergency department of a tertiary care pediatric hospital.

PARTICIPANTS: Sixty-six children aged 5 to 10 years with concerns unrelated to the gastrointestinal tract. Intervention Each participant consumed as much of each solution as they desired during a 15-minute period.

MAIN OUTCOME MEASURES: The primary outcome was each child's rating of taste as measured on a 100-mm visual analog scale (worst taste, 0 mm; best taste, 100 mm). Secondary outcome measures were volume consumed, willingness to consume each liquid again, and the most favored liquid.

RESULTS: All enrolled patients completed all 3 study periods. A significant carryover effect was detected for taste scores (P=.03), which were significantly different with and without adjustment for the carryover effect (P less than .001). Unadjusted values were 65 mm for Pedialyte, 58 mm for Pediatric Electrolyte, and 23 mm for Enfalyte. Differences in mean volume consumed were not significant (Enfalyte, 15 mL; Pediatric Electrolyte, 17 mL; and Pedialyte, 22 mL [P=.44]). The proportion of children who would drink each solution in the future varied significantly between Enfalyte and Pediatric Electrolyte (odds ratio, 0.22; 95% confidence interval, 0.11-0.46) and between Enfalyte and Pedialyte (0.38; 0.25-0.57). There were differences in the identification of the best-tasting solution, with Pedialyte selected by 35 of 66 children (53%), Pediatric Electrolyte by 26 of 66 children (39%), and Enfalyte by 5 of 66 children (8%) (P less than .001).

CONCLUSION: Sucralose-sweetened oral rehydration solutions (Pedialyte and Pediatric Electrolyte) were significantly more palatable than was a comparable rice-based solution (Enfalyte).

18. ED Delirium Associated with Elevated 6-month Mortality

Han JH, et al. Ann Emerg Med. 2010;56:244-252.e1.

Background
Delirium occurs in 8% to 10% of older emergency department (ED) patients. This form of brain dysfunction is characterized by an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. Approximately 1.5 million older patients with delirium will be evaluated in the ED each year in the United States, which is similar to the number of annual acute coronary syndromes, a disease with comparable mortality and morbidity. Despite the magnitude of this problem, emergency physicians miss delirium in up to 75% of cases.

Importance
The lack of delirium recognition may be a result of a dearth of ED outcomes data. Predominantly from inhospital literature, delirium has been shown to be a marker for long-term death in noncritically ill and critically ill inpatients. Unfortunately, hospital-based studies have limited generalizability to the ED population because they exclude patients discharged from the ED and enrollment typically occurs in 24 to 48 hours after admission. In addition, many of these studies include patients who developed delirium during their hospital course, and a significant proportion of inpatients who were classified as having delirium may not have been delirious in the ED.

Even less is known about delirium's effect on mortality in nursing home patients treated in the ED, despite being 7 times more likely to be delirious compared with community-dwelling elders. Conclusions derived from general geriatric data sets have limited external validity to nursing home patients because they have higher rates of dementia, poorer functional status, and higher comorbidity burden. There are approximately 1.5 million nursing home residents in the United States, and 43% of community-dwelling elders will enter a nursing home during their lifetime. Because up to 25% of all nursing home patients will visit the ED for an acute illness, understanding how delirium affects nursing home patients is crucial.

Goals of This Investigation
Because there is a paucity of data about the relationship between delirium in the ED and long-term mortality, and little is known about its effect on nursing home patients, we sought to determine whether delirium is an independent predictor of 6-month mortality in older ED patients, regardless of their admission status, and to assess whether this relationship is modified by nursing home residence.

What question this study addressed: This 628-patient prospective cohort study examined the association between delirium and 6-month mortality.

What this study adds to our knowledge: Mortality at 6 months was much higher among older adults with delirium (37% versus 14%).

How this might change clinical practice: Further research is required to determine whether earlier detection and treatment of delirium alters outcome.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(10)00220-9/fulltext

19. Dantrolene in the treatment of MDMA-related hyperpyrexia: a systematic review

Grunau BE, et al. CJEM 2010;12(5):435-442

Objective: The use of dantrolene in the treatment of hyperpyrexia related to MDMA (3,4-methylenedioxymethamphetamine) is controversial, with little data available to guide clinical decision-making. Although the treatment is recommended by several poison control centres, published data are primarily in the form of case reports and animal and in vitro experiments. We conducted a systematic review to investigate the published evidence regarding the safety and benefits of dantrolene for MDMA-related hyperpyrexia in humans.

Data sources: A systematic search of Embase and MEDLINE was conducted from the earliest possible date to November 2008.

Study selection: All human trials and case reports of MDMA related hyperpyrexia were considered.

Data extraction: Data were abstracted systematically and characteristics including use of dantrolene, adverse reactions attributed to dantrolene, peak temperature, complications from MDMA-related hyperpyrexia and survival were recorded.

Data synthesis: Our search yielded 668 articles of which 53, reporting 71 cases of MDMA-induced hyperpyrexia, met our inclusion criteria. No clinical trials, randomized controlled trials, observational studies or meta-analyses were identified. Dantrolene was used in 26 cases. Patient characteristics were similar in the dantrolene and no dantrolene groups. The proportion of survivors was higher in the dantrolene group (21/26) than in the no dantrolene group (25/45). This difference was especially pronounced in those with extreme (≥ 42°C) and severe (≥ 40°C) fever, with a survival rate of 8 of 13 and 10 of 10, respectively, in the dantrolene group compared with 0 of 4 and 15 of 27 in the no dantrolene group. There were no reports of adverse events attributable to dantrolene with the exception of a possible association with an episode of transient hypoglycemia.

Conclusion: Our systematic review suggests that dantrolene is safe for patients with MDMA-related hyperpyrexia. Dantrolene may also be associated with improved survival and reduced complications, especially in patients with extreme (≥ 42°C) or severe (≥ 40°C) hyperpyrexia, although this conclusion must be interpreted with caution given the risk of reporting or publication bias.

See their related case report below.

Dantrolene for the treatment of MDMA toxicity

Grunau BE, et al. CJEM 2010;5(12):457-459

MDMA (3,4-methylenedioxymethamphetamine), popularly known as “Ecstasy,” was first introduced and patented by Merck & Co., Inc., in 1914 as an appetite suppressant. Currently, its primary role is as an illegal stimulant used to produce a euphoric effect during parties. This case report describes a 31-year-old man who, after taking 3 tablets of Ecstasy, presented to an emergency department with a decreased level of consciousness and became progressively hyperthermic and rigid. During the course of his acute illness, his temperature reached 42.2°C rectally. He was given mechanical ventilation. He was aggressively cooled and dantrolene was initiated. Soon after the administration of dantrolene his temperature decreased and his rigidity began to resolve. The only complication was rhabdomyolysis with a creatine kinase level increasing to over 150 µkat/L. This did not progress to acute renal failure. The patient made a full recovery and was discharged to psychiatry for assessment.

20. Delayed versus immediate defibrillation for out-of-hospital cardiac arrest due to ventricular fibrillation: A systematic review and meta-analysis of randomised controlled trials

Simpson PM, et al. Resusc 2010;81:925-931.

Background
Human studies over the last decade have indicated that delaying initial defibrillation to allow a short period of cardiopulmonary resuscitation (CPR) may promote a more responsive myocardial state that is more likely to respond to defibrillation and result in increased rates of restoration of spontaneous circulation (ROSC) and/or survival. Out-of-hospital studies have produced conflicting results regarding the benefits of CPR prior to defibrillation in relation to survival to hospital discharge. The aim of this study was to conduct a systematic review and meta-analysis of randomised controlled trials comparing the effect of delayed defibrillation preceded by CPR with immediate defibrillation on survival to hospital discharge.

Methods
A systematic literature search of key electronic databases including Medline, EMBASE, and the Cochrane Library was conducted independently by two reviewers. Randomised controlled trials meeting the eligibility criteria were critically appraised according to the Cochrane Group recommended methodology. Meta-analyses were conducted for the outcomes of survival to hospital discharge overall and according to response time of emergency medical services.

Results
Three randomised controlled trials were identified which addressed the question of interest. All included studies were methodologically appropriate to include in a meta-analysis. Pooled results from the three studies demonstrated no benefit from providing CPR prior to defibrillation compared to immediate defibrillation for survival to hospital discharge (OR 0.94 95% CI 0.46–1.94). Meta-analysis of results according to ambulance response time (below 5min or beyond 5min) also showed no difference in survival rates.

Conclusion
Delaying initial defibrillation to allow a short period of CPR in out-of-hospital cardiac arrest due to VF demonstrated no benefit over immediate defibrillation for survival to hospital discharge irrespective of response time. There is no evidence that CPR before defibrillation is harmful. Based on the existing evidence, EMS jurisdictions are justified continuing with current practice using either defibrillation strategy.

21. Meaningful Use of EHRs Will Become Part of Specialty Board Recertification

August 16, 2010 — The federal government wants physicians to become "meaningful users" of electronic health records (EHR) — so much so it that will start giving them cash bonuses in 2011 to go digital.

Becoming a meaningful EHR user also will pay another dividend in the future — helping physicians get recertified by their specialty boards.

Earlier this month, the American Board of Medical Specialties (ABMS) announced it would develop tools to promote meaningful EHR use and incorporate them into its Maintenance of Certification (MOC) program, which its 24 member boards use to push physicians toward lifelong learning and self-assessment. The initiative, at least in its preliminary form, does not baldly make EHR use a condition of recertification. Rather, it takes its cue from the federal government's bonus program and encourages EHR adoption with carrots rather than sticks, said Sheldon Horowitz, MD, special advisor to ABMS President Kevin Weiss, MD, MPH.

"We're trying to make our program attractive," Dr. Horowitz told Medscape Medical News. "We want to help physicians do well with meaningful use and patient care."

Dr. Horowitz said that the objectives of meaningful EHR use — which include improving the quality, safety, and coordination of patient care — overlap with the 6 core professional competencies that the MOC program tries to measure. Among these competencies are a physician's ability to scientifically assess and improve his or her own practice of medicine, as well as operate within the entire healthcare system (ie, coordination of care).

Last month, the Centers for Medicare and Medicaid Services (CMS) published its final version of meaningful-use requirements that physicians must meet to earn incentive money — up to $44,000 under Medicare, or almost $64,000 under Medicaid. Fifteen of the 25 requirements, such as prescribing electronically and using drug interaction and allergy alerts, are mandatory. Of the 10 other requirements, physicians may choose 5 to meet.

Simulated EHR Exercises Are Coming

In its effort to take board recertification into the EHR era, the ABMS will initially work with the American Board of Family Medicine, the American Board of Internal Medicine, and the American Board of Pediatrics — 3 groups that have certified 369,000 physicians. As one of their first projects, the boards will develop 2 self-assessment modules on healthcare information technology, said Dr. Horowitz.

One module will test a physician's knowledge of how to use the technology to manage and analyze patient data, practice evidence-based medicine, and make the right calls on diagnosis and treatment with "decision support." The other module will focus on promoting patient safety through such EHR functions as electronic prescribing and computerized physician order entry.

Dr. Horowitz said the 2 modules will be optional, not required. However, by completing these particular modules, physicians will receive more points toward recertification than they would with other modules.

The remainder of the article: http://www.medscape.com/viewarticle/726967

Lit Bits: Aug 19, 2010

From the recent medical literature...

1. Newer-Generation CT Is Highly Sensitive for Diagnosing Subarachnoid Hemorrhage

But don't put away those lumbar puncture trays just yet.

Older-generation computed tomography (CT) scanners proved too insensitive for a negative scan to rule out the diagnosis of subarachnoid hemorrhage (SAH), making lumbar puncture (LP) necessary in patients with negative scans. In a retrospective chart review, researchers evaluated the sensitivity of newer-generation multidetector CT scanners for diagnosing SAH in 499 patients with suspected SAH who were referred to a Dutch neurosurgical unit from 2000 through 2005.

All patients underwent head CT. Patients with negative CT scans underwent LP (12 hours after onset of symptoms), and cerebrospinal fluid (CSF) samples were analyzed for xanthochromia by spectrophotometry. Patients with positive scans underwent angiography. SAH was diagnosed in 296 patients, based on angiography or CSF findings. Overall, CT scanning had a sensitivity of 99.7% and a specificity of 100% for diagnosing SAH. Sensitivity was 100% for scans performed 1 to 5 days after symptom onset and 96% for those performed thereafter.

Comment: This study suffers from referral bias, with an extremely high proportion of patients ruling in for subarachnoid hemorrhage (almost 60%). Although newer-generation multidetector CT was highly sensitive, the authors note that CT alone should be used to exclude SAH only on days 1 to 3 after symptom onset and scans should be reviewed by a neuroradiologist or neurosurgeon. Although this study takes us a step closer to eliminating the need for lumbar puncture in patients with suspected SAH, keep those LP trays handy until these results are duplicated in a community emergency department setting.

— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch Emergency Medicine August 5, 2010. Citation: Cortnum S et al. Neurosurgery 2010;66:900.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20404693

2. 44-55-66-PM, a Mnemonic That Improves Retention of the Ottawa Ankle and Foot Rules: A Randomized Controlled Trial

Gravel L, et al. Acad Emerg Med. 2010;17:859–864.

Objectives:  Studies have suggested that poor knowledge of the Ottawa Ankle Rules (OAR) limits its clinical impact. This study evaluated the ability of a mnemonic to improve knowledge of the OAR.

Methods:  This was a single-blind randomized controlled trial performed among residents and medical students doing a pediatric emergency medicine rotation. At baseline, all participants were tested for their baseline knowledge of the OAR. The intervention was a standardized information sheet providing a mnemonic of the OAR (44-55-66-PM), while control subjects received its classic description. Block randomization (medical student vs. type of resident) was used. Each participant answered the same questionnaire at the end of rotation (3 weeks later) and via a Web-based survey 5 to 9 months postrandomization. Main outcome measures were knowledge of the components of the ankle rule based on a 13-item criterion grid and the foot rule based on a 10-item criterion grid. All questionnaires were marked at the end of the study by two reviewers blinded to the randomization. Discrepancies in final scores were resolved by consensus. Student’s t-test was performed to compare mean scores on the evaluation between groups using an intention-to-treat approach.


Results:  Among the 206 eligible participants, 96 medical students and 94 residents were recruited and agreed to participate. Primary outcomes were measured in 95% of the participants at 3 weeks postrandomization and in 72% on the long-term follow-up. Participants in both groups were similar with regard to baseline characteristics and prior knowledge of the OAR. Both groups showed improvement in their knowledge of the rule during the study period. At mid-term, knowledge of the OAR was similar for the ankle components (score for mnemonic 10.9; control 10.2; 95% confidence interval [CI] for difference = −0.3 to 1.7) and for the foot (mnemonic 7.6 vs. control 7.5; 95% CI for difference = −0.7 to 0.9). On the long term, randomization to the mnemonic was associated with a better knowledge of the OAR as demonstrated by a higher score for the ankle component (mnemonic 10.1 vs. control 8.9; 95% CI for difference = 0.6 to 1.8) and for the foot (mnemonic 7.8 vs. control 6.5; 95% CI for difference = 0.8 to 1.9).

Conclusions:  Mid-term knowledge of the OAR drastically improved for all participants of the study. The use of the mnemonic 44-55-66-PM was associated with a better long-term knowledge of the OAR among medical students and residents. The improvement in knowledge of the OAR among the control group highlights the importance of using controlled trials for studies evaluating knowledge transfer.

3. Which Antibiotic for Acute Exacerbations of COPD?

Ciprofloxacin offered no benefit over an old standby, trimethoprim-sulfamethoxazole.

Nouira S, et al. Clin Infect Dis 2010;51:143.

BACKGROUND. Although the use of antibiotics in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is largely accepted, controversy remains regarding whether the choice of antibiotic has any impact on outcome. Our aim was to compare the effects of the combination of trimethoprim and sulfamethoxazole and ciprofloxacin in patients treated for severe COPD exacerbation requiring mechanical ventilation.

METHODS. In a randomized, double-blind trial, we included 170 patients with an acute exacerbation of COPD requiring mechanical ventilation. Enrolled patients received trimethoprim-sulfamethoxazole (n = 85) or ciprofloxacin (n = 85) for 10 days. Main outcomes were hospital death and need for an additional course of antibiotics. Secondary outcomes were duration of mechanical ventilation, length of hospital stay, and exacerbation-free interval.

RESULTS. Combined hospital death and additional antibiotic prescription rates were similar in the 2 groups (16.4% vs 15.3% for trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 1.1%; 95% confidence interval [CI] -9.8% to 12.0%; P = .832). Hospital death occurred in 7 patients (8.2%) receiving trimethoprim-sulfamethoxazole and 8 patients (9.4%) receiving ciprofloxacin (difference, -1.2%; 95% CI, -9.7 to 7.3; P = .90). The need for an additional antibiotic course was observed in 8 patients in the trimethoprim-sulfamethoxazole group and 5 patients in the ciprofloxacin group (difference, 2.3%; 95% CI, -5.4 to 10.0; P = .549). The mean exacerbation-free interval (+/- standard deviation) was similar in both treatment groups (83 +/- 25 vs 79 +/- 22 for the trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 4 days; 95% CI, -15 to 19 days; P = .41). Duration of mechanical ventilation and hospital stay was not significantly different between the 2 groups.

CONCLUSIONS. In patients with acute exacerbation of COPD requiring mechanical ventilation, efficacy of trimethoprim-sulfamethoxazole was not inferior to ciprofloxacin.

4. The Relationship between the Emergent Primary PCI Quality Measure and Inpatient AMI Mortality

Khare RK, et al, Acad Emerg Med. 2010;17:793-800.

Background: In the setting of acute ST-segment elevation myocardial infarction (STEMI), reperfusion therapy with emergent primary percutaneous coronary intervention (PCI) significantly reduces mortality. It is unknown whether a hospital's performance on the Centers for Medicare & Medicaid Services (CMS) quality metric for time from patient arrival to angioplasty is associated with its overall hospital acute myocardial infarction (AMI) mortality rate.

Objectives: The objective of this study was to evaluate if hospitals with higher performance on the time-to-PCI quality measure are more likely to achieve lower mortality for patients admitted for any type of AMI.

Methods: Using merged 2006 data from the Nationwide Inpatient Sample (NIS), the American Hospital Association (AHA) annual survey, and CMS Hospital Compare quality indicator data, we examined 69,101 admissions with an International Classification of Diseases, Ninth Revision (ICD-9)-coded principal diagnosis of AMI in the 116 hospitals that reported more than 24 emergent primary PCI admissions in that year. Hospitals were categorized into quartiles according to percentage of admissions in 2006 that achieved the primary PCI timeliness threshold (time-to-PCI quality measure). Using a random effects logistic regression model of inpatient mortality, we examined the significance of the hospital time-to-PCI quality measure after adjustment for other hospital and individual patient sociodemographic and clinical characteristics.

Results: The unadjusted inpatient AMI mortality rate at the 27 top quartile hospitals was 4.3%, compared to 5.1% at the 32 bottom quartile (worst performing) hospitals. The risk-adjusted odds ratio (OR) of inpatient death was 0.83 (95% confidence interval [CI] = 0.72 to 0.95), or 17% lower odds of inpatient death, among patients admitted to hospitals in the top quartile for the time-to-PCI quality measure compared to the case if the hospitals were in the bottom 25th percentile.

Conclusions: Hospitals with the highest and second highest quartiles of time-to-PCI quality measure had a significantly lower overall AMI mortality rate than the lowest quartile hospitals. Despite the fact that a minority of all patients with AMI get an emergent primary PCI, hospitals that perform this more efficiently also had a significantly lower mortality rate for all their patients admitted with AMI. The time-to-PCI quality measure in 2006 was a potentially important proxy measure for overall AMI quality of care.

5. Getting Into Med School without Hard Sciences

By ANEMONA HARTOCOLLIS. Published: July 29, 2010. For generations of pre-med students, three things have been as certain as death and taxes: organic chemistry, physics and the Medical College Admission Test, known by its dread-inducing acronym, the MCAT.

So it came as a total shock to Elizabeth Adler when she discovered, through a singer in her favorite a cappella group at Brown University, that one of the nation’s top medical schools admits a small number of students every year who have skipped all three requirements.

Until then, despite being the daughter of a physician, she said, “I was kind of thinking medical school was not the right track for me.”

Ms. Adler became one of the lucky few in one of the best kept secrets in the cutthroat world of medical school admissions, the Humanities and Medicine Program at the Mount Sinai medical school on the Upper East Side of Manhattan.

The program promises slots to about 35 undergraduates a year if they study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average.

For decades, the medical profession has debated whether pre-med courses and admission tests produce doctors who know their alkyl halides but lack the sense of mission and interpersonal skills to become well-rounded, caring, inquisitive healers.

That debate is being rekindled by a study published on Thursday in Academic Medicine, the journal of the Association of American Medical Colleges. Conducted by the Mount Sinai program’s founder, Dr. Nathan Kase, and the medical school’s dean for medical education, Dr. David Muller, the peer-reviewed study compared outcomes for 85 students in the Humanities and Medicine Program with those of 606 traditionally prepared classmates from the graduating classes of 2004 through 2009, and found that their academic performance in medical school was equivalent.

Remainder of NYT article: http://www.nytimes.com/2010/07/30/nyregion/30medschools.html
Acad Med (full-text free): http://journals.lww.com/academicmedicine/Fulltext/2010/08000/Challenging_Traditional_Premedical_Requirements_as.26.aspx

6. Wound Closure after 6 Hours Does Not Increase Infection Rates

Location of the wound was a more important predictor of infection than the time to closure.

Background: The dogma that traumatic wounds should not be sutured after 6 h is based on an animal experiment by P L Friedrich in 1898. There is no adequately powered prospective study on this cut-off of 6 h to confirm or disprove the dogma. The aim of this study was to provide evidence against the dogma that wounds should be sutured within 6 h after trauma.

Method: 425 patients were included in a prospective cohort study. Patients' wounds were closed, independent of time after trauma. All patients were seen after 7–10 days for removal of stitches and wound control on infection.

Results: Of the 425 patients, 17 were lost to follow-up. Of the remaining 408 patients, 45 had wounds older than 6 h after trauma. At follow-up 372 patients (91%) had no infection and 36 patients had redness of the suture sites or worse. 11 patients (2.7%) had general redness or pus. Of those with a wound older than 6 h, three of 45 (6.7%) wounds were infected, versus 30 of 363 (9.1%) in wounds younger than 6 h (p=0.59).

Conclusion: In everyday practice wounds are sutured regardless of elapsed time. Here an attempt was made to present the evidence for this daily routine, contrary to Friedrich's Dogma.

Editor’s note: For those who would like to read Friedrich’s original article, here’s the reference: Friedrich PL. Die aseptische Versorgung frischer Wunden, unter Mitteilung yon Their versUchen uber die auskeimungszeit yon Infectionserre gern in frischen Wunden. Arch. Klin. Chir. 1898;57:288. Full-text here: http://bit.ly/anGvIs

7. Vast Majority of ED Visits Are Urgent, CDC Reports

Martha Kerr. August 12, 2010 — A report issued yesterday by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, shows that the percentage of nonurgent visits to the nation's emergency departments (EDs) is low and that this number has been decreasing during the past several years, whereas the total number of visits is steadily increasing.

According to the latest CDC report, the "National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary," only 7.9% of all visits were nonurgent. This is down from 12.1% in 2006. Meanwhile, the total number of visits to EDs increased 23% between 1997 and 2007, with early indications pointing to a record high number of visits for 2008.

Infants younger than 12 months had the highest visit rate, at 88.5 visits per 100 infants. The second highest visit rate was by adults aged 75 years and older, with 62 visits per 100 people.

Approximately 15% of all visits were by the uninsured, and roughly 25% were by patients insured by either Medicaid or the State Children's Health Insurance Program.

Only 0.1% of patients died in the ED.

"We do an excellent job of stabilizing and treating our patients, but the persistent problems of overcrowding, ambulance diversion, and boarding admitted patients in the [ED] are not going away," Angela Gardner, MD, president of the American College of Emergency Physicians (ACEP), said in a statement. "We know from the Massachusetts experience that visits will continue to rise with health care reform. We also know that as Baby Boomers age, a tsunami of patients in need of emergency care is just around the corner. We need help and we need it now."

The report shows that 64.7% of all ED visits occurred outside regular business hours. "Most doctors' offices are open for around 45 hours a week, as opposed to the 168 hours a week [EDs] are open," Dr. Gardner said. "That nearly two-thirds of emergency patients came to the [ED] between 5 p.m. and 8 a.m. during the week or on weekends highlights the unpredictable nature of health emergencies."

Overall, 12.5% of patients were admitted as inpatients, 2.1% were admitted to an observation unit, and 1.8% were transferred to a different hospital.

Overcrowding was a significant issue, according to the 2007 report, with the primary contributor to the problem being delays in moving the sickest patients to inpatient beds. Admitted patients were often boarded in the EDs or hospital hallways for hours to days, Dr. Gardner said, resulting in overcrowding and diversion of incoming ambulances to other hospitals.

On a side note, ACEP points out that the CDC says "this is the last fully detailed report of its kind to be issued about [ED] visits." ACEP is asking the CDC to reconsider.

"It is essential to know what is happening in our [EDs] as we implement health care reform," Dr. Gardner said. "This report is rich in data about who our patients are, how old they are and why they are seeking care in the [ED]. From a planning perspective, this information is invaluable."

Full CDC report: http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf

8. Clinical Outcomes of Children Treated with Intravenous Prochlorperazine for Migraine in a Pediatric ED

Trottier ED, et al. J Emerg Med. 2010;39:166-173.

Background: Prochlorperazine is the only treatment that has been studied so far in a randomized controlled trial and found to reduce pain at 1 h in children with migraine who presented to an emergency department (ED).

Objective: To evaluate the rate of treatment failure associated with prochlorperazine used in children with severe migraine in a pediatric ED.

Methods: This study was a retrospective chart review of patients younger than 18 years of age who visited the ED of a tertiary care pediatric hospital between November 2005 and June 2007. All patients diagnosed with migraine by the emergency physicians were included in the study. Charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. Inter-rater agreement was measured. Prochlorperazine treatment failure was defined as either administration of further rescue therapy, a hospitalization, or a return visit to the ED within 48 h for symptom recurrence or side effects from the medication.

Results: Prochlorperazine was administered in 92 episodes of migraine, including 43 confirmed by a pediatric neurologist; all received diphenhydramine to prevent akathisia. A total of 13 (14%) of these patients had a treatment failure: 8 patients received one or more further rescue therapies after the administration of prochlorperazine; 5 patients were hospitalized, including 3 who had received further rescue therapy; and 3 patients returned to the ED within 48 h due to symptom recurrence.

Conclusion: There was a treatment failure rate of 14% with the use of prochlorperazine in association with diphenhydramine for severe migraine in children seen in a pediatric ED.

9. Do retinal haemorrhages occur in infants with convulsions?

Curcoy AI, et al. Arch Dis Child. 2009 Nov;94(11):873-5.

AIM: To determine the prevalence of retinal haemorrhages in infants presenting with convulsions and admitted to hospital, and to consider whether this finding indicates shaken baby syndrome.

METHODS: Prospective study of children aged 15 days to 2 years admitted with a diagnosis of first convulsion over a 2-year period (May 2004-May 2006). All infants were examined by an experienced ophthalmologist using indirect ophthalmoscopy within 72 h of admission.

RESULTS: 182 of 389 children seen in the accident and emergency department were admitted and two were found to have retinal haemorrhages. Both children were eventually diagnosed as being abused.

CONCLUSIONS: Convulsions alone are unlikely to cause retinal haemorrhages in children under 2 years of age.

10. RICH and PRINCE Probe Prehospital Therapeutic Hypothermia after Cardiac Arrest

Reed Miller. August 9, 2010 (Melbourne, Australia) — Two studies published last week are shedding light on the possibilities and limitations of prehospital "brain cooling" after cardiac arrest. In the Rapid Infusion of Cold Hartmann's (RICH) study, paramedic cooling with a rapid infusion of a large volume of ice-cold intravenous fluid (Hartmann's solution) after resuscitation did not appear to improve the outcomes of cardiac arrest patients with ventricular fibrillation more than waiting until the patient reaches the hospital to begin cooling. In the second study, the Pre-Resuscitation Intranasal Cooling Effectiveness (PRINCE) trial, investigators showed significant reductions in time required to achieve therapeutic levels of cooling, using coolant gases and oxygen given directly into the nasal passages.

Both studies were published online in the August 2, 2010 issue of Circulation.

Previous studies have suggested that therapeutic hypothermia can improve outcomes in patients who suffer out-of-hospital cardiac arrests, but the question of whether prehospital cooling further boosts outcomes is not clear, RICH researchers Dr Stephen Bernard (Ambulance Victoria, Melbourne, Australia) and colleagues explain.

Remainder of the article: http://www.medscape.com/viewarticle/726547

Abstracts
RICH: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.109.906859v1
PRINCE: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.109.931691v1

11. Racial and Sex Differences in ED Triage Assessment and Test Ordering for Chest Pain, 1997–2006

Lopez L, et al. Acad Emerg Med. 2010;17:801–808.

Objectives:  This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

Methods: A nationally representative ED data sample for all adults (≥18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997–2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

Results:  Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

Conclusions:  Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect “downstream” clinical care and help eliminate observed disparities in cardiac outcomes.

12. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the ED

Stein EG, et al. AJR Am J Roentgenol. 2010;194:392-7.

OBJECTIVE: The purpose of our study was to determine whether the radiation exposure to patients with suspected pulmonary embolism (PE) could be decreased by safely increasing the use of ventilation-perfusion (V/Q) scanning and decreasing the use of CT pulmonary angiography (CTPA) through an educational intervention.

MATERIALS AND METHODS: Collaborative educational seminars were held among the radiology, nuclear medicine, and emergency medicine departments in December 2006 and January 2007 regarding the radiation dose and accuracies of V/Q scanning and CTPA for diagnosing PE. To reduce radiation exposure, an imaging algorithm was introduced in which emergency department patients with a clinical suspicion of PE underwent chest radiography. If the chest radiograph was normal, V/Q scanning was recommended, otherwise CTPA was recommended. We retrospectively tallied the number and results of CTPA and V/Q scanning and calculated mean radiation effective dose before and after the intervention. False-negative findings were defined as subsequent thromboembolism within 90 days.

RESULTS: The number of CTPA examinations performed decreased from 1,234 in 2006 to 920 in 2007, and the number of V/Q scans increased from 745 in 2006 to 1,216 in 2007. The mean effective dose was reduced by 20%, from 8.0 mSv in 2006 to 6.4 mSv in 2007 (p less than 0.0001). The patients who underwent CTPA and V/Q scanning in 2006 were of similar age. In 2007, the patients who underwent V/Q scanning were significantly younger. There was no significant difference in the false-negative rate (range, 0.8-1.2%) between CTPA and V/Q scanning in 2006 and 2007.

CONCLUSION: The practice patterns of physicians changed in response to an educational intervention, resulting in a reduction in radiation exposure to emergency department patients with suspected PE without compromising patient safety.

13. What’s Up with the “Vulnerable Atherosclerotic Plaque”? A Review of the Literature

Alsheikh-Ali AA, et al. Ann Intern Med 2010;153,

Full-text (free): http://www.annals.org/content/early/2010/08/13/0003-4819-153-6-201009210-00272.full

14. Mid-Arm Circumference Estimates Children's Weight in Emergencies

By Rob Goodier. NEW YORK (Reuters Health) Aug 06 - Doctors have developed a new tool for estimating school-age children's weight while treating them for trauma and other emergencies: a formula based on a mid-arm circumference measurement.

"This technique is intended as a 'rough estimate' in pediatric resuscitation, to better calculate appropriate drug doses," lead researcher Dr. Giles Cattermole at the Chinese University of Hong Kong told Reuters Health by email.

The formula is weight (kg) = (mid-arm circumference (cm) - 10) * 3.

According to a report published online July 12th in Resuscitation, this formula was at least as accurate as other methods when used for school-age children. And it may be more convenient than others, given that the arm is already exposed for measuring blood pressure and gaining venous access.

Dr. Cattermole and his team compared their new formula to three other techniques commonly used: estimates based on age, foot length and height using a color-coded Broselow tape.

In a study group of 1,391 children ages 1 to 11, the mid-arm circumference (MAC) measurement outperformed the other three parameters, both overall and in the oldest age group studied (9 to 11 years). In fact, 171 of the children were too tall for the Broselow tape.

The MAC correlation with weight was not statistically significant in the youngest group (1 to 5 years), however.

In no group was age or foot length the most accurate.

Multiple regression models showed that MAC was the most accurate method in the oldest group, and the Broselow height method was the most accurate in the youngest children. The two methods were similarly accurate in the 6-to-8-year-olds.

The study was population based, testing all the children in 14 schools and kindergartens who had their parents' permission to participate.

The MAC formula is simple and linear, the researchers say. It could become more nuanced using a color-coded tape system like the Broselow method, in which weight groups are categorized by color.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20619953

15. Images for the Emergency Physician

Complications of Otitis Media
http://www.amjmed.com/article/S0002-9343(10)00349-9/fulltext

16. Risk for Acute Bacterial Meningitis in Children with Complex Febrile Seizure

Bacterial meningitis is uncommon in children who present with a first complex febrile seizure.

In a retrospective chart review, researchers examined the rate of acute bacterial meningitis (ABM) in 526 otherwise healthy children (age range, 6–60 months) who presented with their first complex febrile seizure (focal seizures, duration over15 minutes, multiple seizures within 24 hours) to a tertiary care pediatric emergency department in Boston between 1995 and 2008.

A total of 156 children (29%) were pretreated with antibiotics. Of 340 patients (65%) who underwent lumbar puncture (LP), 14 (2.7%) had cerebrospinal fluid (CSF) pleocytosis (white blood cell count over 7 cells/µL). Three patients (0.9%) were diagnosed with ABM; two had Streptococcus pneumoniae in CSF culture and one, in whom LP was not successful, had S. pneumoniae in blood culture. One patient with ABM was nonresponsive at presentation, another had a bulging fontanelle and nuchal rigidity, and the third patient had two brief generalized seizures within 24 hours. Two patients with ABM presented before the introduction of the conjugate pneumococcal vaccine. Among the 161 (of 186) children who did not undergo LP and returned for follow-up, none had ABM.

Comment: Bacterial meningitis is uncommon in otherwise healthy children with a first complex febrile seizure. The authors concluded that "LP should be performed on the basis of clinical suspicion and additional signs and symptoms that are suggestive of meningitis." However, they do not provide specific suggestions about when to perform LP. The prevalence of acute bacterial meningitis in children who present with a first complex febrile seizure and no other signs and symptoms of meningitis is low. Thus, physicians could consider forgoing LP — after a period of observation — in well-appearing children without overt signs of meningitis whose neurological status returns to baseline.

— Howard Bauchner, MD, and Katherine Bakes, MD. Published in Journal Watch Pediatrics and Adolescent Medicine July 28, 2010. Citation: Kimia A et al. Pediatrics 2010;126:62.

Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20566610

17. New AHA/ASA Guidelines on Management of Spontaneous Intracerebral Hemorrhage

July 30, 2010 — The American Heart Association/American Stroke Association has released a new guideline on the management of spontaneous intracerebral hemorrhage (ICH).

ICH has long been recognized as one of the most severe forms of stroke, among the most devastating neurologic injuries, and the view of many has been that there is not much to be done for these patients, said lead study author Lewis B. Morgenstern, MD, from the University of Michigan, Ann Arbor.

"The clear message that we want to send with this guideline is that intracerebral hemorrhage is a very treatable disorder, with very guideline-concordant, aggressive critical care," Dr. Morgenstern told Medscape Medical News. "There's a lot of evidence in the guideline of things that are shown to be effective and improve outcome."

There's also a lot of evidence that if care is not aggressive, "outcome is very bad," he added. "So the hope of the writing committee is that clinicians will use this to guide their appropriate and aggressive treatment for patients who have intracerebral hemorrhage."

The guideline, which has been reviewed and the educational content affirmed by the American Academy of Neurology, as well as the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, was published online July 22 and will appear in the September issue of Stroke. The guideline applies only to spontaneous ICH, not ICH subsequent to trauma.

Remainder of the article: http://www.medscape.com/viewarticle/726066

Guidelines (free): http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181ec611b

18. The Effect of Physician Triage on ED Length of Stay

Han JH, et al. J Emerg Med. 2010;39:227-233.

Background: Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. Objectives: We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion.

Methods: This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period.

Results: We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month.

Conclusion: Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.

19. Intranasal Medication Delivery for Children Reviewed

Laurie Barclay, MD. August 9, 2010 — The most frequent pediatric indications for intranasal medication delivery are pain control, anxiolysis, and seizure control, according to a review published online August 9 in Pediatrics. Other potential indications for intranasal medication delivery not reviewed in this article include the treatment of epistaxis, pretreatment before nasogastric tube insertion, and administration of naloxone for reversal of narcotic overdose.

"Intranasal delivery offers unique advantages that may allow more efficient use of resources, more rapid patient care, and higher patient and provider satisfaction," write Timothy R. Wolfe, MD, from University of Utah School of Medicine in Salt Lake City, and Darren A. Braude, MD, from the University of New Mexico School of Medicine in Albuquerque. "The highly vascularized nasal mucosa and the olfactory tissue in direct contact with the central nervous system allow nasally administered drugs to be rapidly transported into the bloodstream and brain, with onsets of action approaching that of intravenous therapy. First-pass drug metabolism via the liver is also avoided, resulting in high bioavailability of many medications."

Except for orally and intranasally administered medications, most formulations require a needle injection, which may be painful, anxiety-provoking, and time-consuming for staff, who must be trained in proper injection technique and who are exposed to the risks for needle stick injury. In comparison, intranasal delivery of medication is relatively painless, inexpensive, and easy to administer with minimal training.

Specific uses of intranasally delivered medications include the following:

• For pain control, fentanyl 1.5 to 2.0 μg/kg. This may be titrated every 15 minutes as needed. Patients should be monitored for respiratory depression. It may be appropriate to administer oral medications concurrently so that they take effect as the intranasal fentanyl effect wears off.
• For anxiolysis, midazolam 0.4 to 0.5 mg/kg. The concentrated form (5 mg/mL) should be used, because other concentrations may be ineffective when administered intranasally. The patient and family should be advised that a burning sensation may last for 30 seconds.
• For seizures, midazolam 0.2 mg/kg. As for anxiolysis, the concentrated form (5 mg/mL) should be used for intranasal delivery.

Intranasal opiates may be especially useful for minor fractures, large abrasions, burns, wound-dressing changes, extremity fractures, and other acutely painful conditions in children. For treatment of acute pain, intranasal opiates have been shown to be as effective as intravenous morphine and faster than intramuscular morphine.

Procedures in which light procedural sedation and anxiolysis may be achieved with intranasal medications include laceration repair, magnetic resonance imaging and computed tomography scans, burn-dressing changes, dental extractions, endoscopies, and central venous port access. Although intranasal midazolam is the most commonly studied drug in these settings, other options may include intranasal fentanyl, ketamine, sufentanil, dexmedetomidine, and combinations of these drugs.

Intranasal midazolam is effective for prolonged seizures because it easily and rapidly crosses the nasal mucosa and the blood-brain barrier, with similar efficacy to intravenous diazepam but faster onset because of the lack of need to start an intravenous line. Intranasal midazolam and lorazepam are also safe for treating seizures outside of the hospital setting, and intranasal midazolam may be a useful option for treating status epilepticus when intravenous access is not immediately available.

Specific considerations for administering intranasally delivered medications include the following:

• Deliver immediately to allow absorption while the airway is being supported.
• The nostril should be inspected for significant amounts of blood or mucous discharge that could limit absorption of a nasal medication. When these are present, alternative delivery options should be considered, or it may be appropriate to suction the nasal passage before medication delivery.
• Deliver half of the medication dose up each nostril, which doubles the available mucosal surface area (vs a single nostril) for drug absorption and increases the rate and amount of absorption.
• The most concentrated form available of the medication should be used, because dilute forms are less effective for intranasal delivery.
• The ideal volume for intranasal medication delivery is 0.2 to 0.3 mL of medication per nostril, and volume per nostril should not exceed 0.5 to 1.0 mL. Two separate doses may be used when a higher volume is needed, with a few minutes between doses to allow the first dose to absorb.

Adverse effects of nasal medications seldom occur. The most common adverse effect is transient nasal burning and irritation with midazolam. Except with high doses of intranasal sufentanil for induction during surgery, oversedation has not been reported for intranasal medications, including fentanyl or midazolam.

"Intranasal medication delivery is an effective method of delivering analgesia, anxiolysis, and anticonvulsants to pediatric patients," the review authors conclude. "In the properly selected patient, nasal administration can reduce time to medication delivery and onset, reduce medical staff resource use, eliminate needle-stick exposure risk, and eliminate pain from the injection, thereby leading to improved patient and parent satisfaction. Pediatricians, pediatric emergency physicians, and emergency medical services medical directors should consider adopting this delivery method for medications and indications that are appropriate to their practice setting."

Dr. Wolfe is affiliated with Wolfe Tory Medical, Inc, the maker of the MAD nasal drug delivery device. Dr. Braude has disclosed no relevant financial relationships.

Pediatrics. Published online August 9, 2010.

20. Straddling Patients on a Stretcher for CPR Works Fine

NEW YORK (Reuters Health) Jul 30 - Pumping on a patient's chest during CPR while the stretcher is moving works just fine, Chinese researchers have found.

By straddling patients on the stretcher, paramedics can get them to and from the ambulance while still doing cardiopulmonary resuscitation (CPR).

What hadn't been clear was how that precarious position would affect the quality of chest compressions if the paramedics didn't have the balance of a bull rider.

So the researchers, led by Dr. Zhou Yaxiong at West China Hospital of Sichuan University in Chengdu, had 20 medical students do chest compressions on a resuscitation dummy that measured the quality of their work. They would do compressions for one minute, both on the floor and on a moving stretcher.

When the researchers examined the data from the dummy, they found no difference in compression rate, depth or efficacy between the two positions. However, the students were able to start CPR about seven seconds earlier when they didn't have to mount the stretcher, and they said it was more comfortable on the floor.

In the report, the researchers thank the students for their "enthusiastic collaboration" and note that none of them fell off the stretcher.

In clinical terms: "Paramedics do not necessarily need to stop transporting the victims while external chest compression is in progress but can perform straddling external chest compression on a moving stretcher instead," the authors reported online July 20th in Resuscitation.

"By doing so, time for transporting victims to the emergency department to get advanced life support may be shortened."

Dr. Dana Edelson, associate chair of the CPR Committee at the University of Chicago, said the results were surprising.

"It goes against conventional wisdom that moving on a stretcher you would do CPR of the same quality as when you are on the floor," she told Reuters Health, adding that more research was needed to confirm the findings.

She stressed that it wasn't clear at this point that getting to the hospital sooner meant a better outcome. And the larger size of most Americans compared with Chinese might also make straddling patients a tougher job in the U.S.

"The general recommendation is still as far as possible to continue doing CPR at the scene and focus on doing the best CPR you can muster," she said.

In case you were wondering: Doing CPR while walking alongside a moving stretcher, instead of straddling the patient, doesn't work as well, according to previous studies.

It appears that mouth-to-mouth resuscitation - shown to be of limited value in another study last week - while straddling dummies on a moving stretcher has not yet been studied.

Resuscitation 2010. In press

Abstract: http://www.resuscitationjournal.com/article/S0300-9572(10)00312-6/abstract

21. Malpractice Threat to Physicians Pervasive, AMA Study Finds

Mark Crane. August 5, 2010 — More than 42% of physicians have been sued for medical malpractice at some point in their careers, and more than 20% were sued at least twice, according to a new American Medical Association (AMA) report.

An average of 95 claims were filed for every 100 physicians — almost 1 per physician — the AMA's Physician Practice Information survey of 5825 physicians, fielded in 2007 and 2008, found.

Despite the pervasive threat of litigation across 42 different specialties surveyed, two thirds of claims are dropped or dismissed, and physicians prevail 90% of the time in cases that go to trial, the study found. Still, the costs to physicians in terms of malpractice premiums and to the entire healthcare system resulting from the practice of defensive medicine are quite high. Average defense costs per claim range from a low of $22,000 among claims that are dropped or dismissed to a high of more than $100,000 for cases that go to trial.

"Even though the vast majority of claims are dropped or decided in favor of physicians, the understandable fear of meritless lawsuits can influence how and where physicians practice, when they retire, and how often they practice wasteful defensive medicine," AMA Immediate Past-President J. James Rohack, MD, told Medscape Medical News. "This litigious climate hurts patients' access to physician care at a time when the nation is working to reduce unnecessary healthcare costs.

"Unfortunately, there are no real surprises in this study for us," said Dr. Rohack, a cardiologist in Temple, Texas. "It reconfirms the need for a solution to our current tort system. If the nation is ever going to control the rise in healthcare costs, we have to eliminate wasteful defensive medicine spending."

Other highlights in the report include:

• Nearly 61% of physicians aged 55 years and older have been sued.
• There is wide variation in the effect of liability claims between specialties. The number of claims per 100 physicians was more than 5 times greater for general surgeons and obstetricians/gynecologists than it was for pediatricians and psychiatrists.
• Before they reach the age of 40 years, more than 50% of obstetricians/gynecologists have already been sued.
• Ninety percent of general surgeons aged 55 years and older have been sued.
"In any single year, being sued is a rare event. Only 5 percent of physicians had claims filed against them in that time frame. Over the length of a career, however, claims are much more common," the report found.

Using data compiled by the Physician Insurers Association of America, a group of physician-owned or physician-operated liability carriers, the AMA survey found:

• Sixty-five percent of claims were dropped, dismissed, or withdrawn; 25.7% were settled; 4.5% were decided by alternative dispute mechanism; and 5% were resolved by trial, with the defendant prevailing in 90% of those tried cases.
• Median indemnity payments were $200,000 for settled claims and $375,000 for tried claims.

Pediatricians and psychiatrists had the lowest incidence of claims. Less than 30% of physicians in either specialty were sued. General surgeons and obstetricians/gynecologists had the highest incidence of claims. Nearly 70% of physicians in those specialties were sued, and more than 200 career claims were filed for every 100 physicians.

Twice as many male physicians had been sued (47.5%) compared with female physicians (23.9%). Male physicians had more than twice as many career claims per 100 physicians, at 111 for men compared with 41 for women. There are several reasons for that disparity. Male physicians are concentrated in the specialties with the highest levels of claims, and female physicians are concentrated in those with the lowest levels. Women also are newer entrants into the medical workforce, so the men had a longer time period, or length of exposure, during which to accumulate claims. Male physicians also worked on average 5 more hours per week than women, resulting in greater exposure. Finally, male physicians were more likely to be practice owners than women.

Practice owners were about 14 percentage points more likely to be sued than employees (47.5% vs 33.4%) because owners incur claims from other physicians and employees of their practices.

The report concludes that the malpractice system "gets it wrong" in terms of compensation for medical errors on both sides of the equation. Citing a 2006 study (N Engl J Med. 2006;354:2024-2033), the report said 27% of claims involving errors were uncompensated. On the flip side, the same percentage of compensated claims did not involve a medical error.

The AMA cites its report to lobby for "proven medical liability reforms to lower health care costs and keep physicians caring for patients," especially caps on awards for pain and suffering. "The findings in this report validate the need for national and state medical liability reform to rein in our out-of-control system where lawsuits are a matter of when, not if, for physicians," said Dr. Rohack.

The AMA favors caps on awards for noneconomic damages. "We know they work," Dr. Rohack said. "Before the reforms in Texas in 2003, obstetricians, neurosurgeons, orthopaedists, and other high-risk specialists were leaving the state. Patients had to travel long distances to see these specialists."

Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change, based in Washington, DC, said the report shows that the threat faced by physicians, particularly in the high-risk specialties, is pervasive.

"We have long known that the medical liability system is a highly ineffective and inefficient mechanism to improve quality," Dr. Ginsburg said. "As the delivery system advances in the area of quality measurement, the crude and poorly targeted liability system seems to be even more inappropriate. In fact, the malpractice system is really obsolete in terms of improving quality and compensating victims."

Dr. Ginsburg argues that the AMA should "aim higher" in its reform efforts. Caps on awards are "a Band-Aid, not true reform. It may reduce the volume of claims and payouts through the system but doesn't improve quality. And the opposition to caps is so dug in that it may be impossible to achieve anyway.

"There are more ambitious proposals, such as granting safe harbors for care delivered in accord with accepted practice guidelines," he added. "Care delivered consistently with those guidelines should be protected." Pilot projects such as special health courts where judges experienced in malpractice cases choose their own experts and decide a case without a jury also are promising, he said.

Dr. Rohack said the AMA also favors these reforms but believes that caps on awards are a proven benefit to physicians.

The AMA Report: http://www.ama-assn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf